Provider Demographics
NPI:1043511439
Name:POLISI, MELODY (LCSW-R)
Entity type:Individual
Prefix:MRS
First Name:MELODY
Middle Name:
Last Name:POLISI
Suffix:
Gender:F
Credentials:LCSW-R
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:186 DORCHESTER RD
Mailing Address - Street 2:
Mailing Address - City:GARDEN CITY SOUTH
Mailing Address - State:NY
Mailing Address - Zip Code:11530
Mailing Address - Country:US
Mailing Address - Phone:917-468-3731
Mailing Address - Fax:
Practice Address - Street 1:62-40 WOODHAVEN BLVD
Practice Address - Street 2:
Practice Address - City:REGO PARK
Practice Address - State:NY
Practice Address - Zip Code:11374
Practice Address - Country:US
Practice Address - Phone:917-468-3731
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-16
Last Update Date:2010-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR055398-1104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker